Review of "Out of the Shadows"

E. Fuller Torrey is one of the more internationally well
known spokespersons on mental health issues and has produced a large number of
books and papers detailing his views that mental illnesses are biological brain
diseases the same as Alzheimer’s and Parkinson’s disease. Linked to this view,
and apparently implied by it, are the notions that the widespread provision of
hospital facilities is the appropriate social response to mental illness, and
that a greater degree of coercion is necessary to ensure that those who suffer
from mental illness accept their need for care, and comply with treatment
regimes prescribed by psychiatrists. The crisis referred to in the title is the
result of the mistaken policy of deinstitutionalisation and the excessive
freedoms afforded the mentally ill.

The thesis of the book is contained in the first chapter,
where the treatment of mental illness is compared to treatment for heart
disease. From this comparison, a case for the treatability of mental illness is
developed, together with an outline of the scale of reduction in hospital beds
between 1954 and 1994. Deinstitutionalisation is described as a ‘psychiatric Titanic,’ a disaster that has lead to
thousands of mentally ill Americans being denied the care and treatment which
modern psychiatry is able to provide. As a result, the mentally ill now make up
substantial proportions of the homeless, the indigent and populations of
correctional facilities. They represent a substantial risk of violence to other
members of the community and of harm and neglect to themselves.

The book explores issues of homelessness, incarceration,
violence and accommodation as they affect people with mental illness. There is
a long chapter on funding and organisation of mental health and related social
services, and a critique of the current standard of dangerousness used to
invoke involuntary committal. Torrey attacks the ideology of ‘mental health’,
which in his view distracts the proper focus of psychiatry from those most in
need of treatment, the severely mentally ill. He concludes by arguing that
psychiatry should be assimilated into neurology, as the case for a biological
basis for mental illness is well proved. Torrey’s assembly of state by state
numbers of inpatient beds and their reduction makes striking reading. Matched
to figures for homelessness and correctional incarceration the argument that
deinstitutionalisation is the root cause of these ills appears compelling. If
mental illness were indeed as treatable as heart disease the case for reopening
hospital beds would be impressive. However the case for a purely biological
model of mental illness, and for more coercive intervention requires closer
examination.

Within the book there is an assumption that the level of
hospitalisation seen in 1954 can be used as a default against which to measure
the adequacy of current service provision. However, Torrey himself acknowledges
that the institutions of the 20th century became overcrowded centres of
custodial containment that offered little therapeutic benefit to the majority
of their patients. There is a not uncommon public perception, shared by many
health professionals, that the current problems of community care can be viewed
against a backdrop of a more humane era in which societies understood and met
their responsibilities to the mentally ill. However, this is a rather naïve
reading of the history of mental health care, and hardly an adequate basis on
which to develop contemporary mental health services.

Several times Torrey makes the point that the effect of
sensationalist media reporting of incidents of violence linked to mental
illness is that the public loses trust in psychiatric professionals. However
although he recognises that the link between mental illness and violence is
often overstated, he emphasises that ‘there is
an association between acts of violence and mental illness’ (original emphasis,
p. 57), apparently accepting that the degree of known risk justifies both
acknowledgement of that risk, and its overstatement in various forms of media.
This is a frequently used and rather simplistic treatment of media portrayal of
risk, and it is disappointing that this aspect of mental health care is not
subjected to more critical treatment. However there is an important message in
this book that health professionals have an obligation to understand and
respond effectively to risk, a message that is sometimes lost in health
professionals’ attempts to reduce the stigma associated with mental illness.

An issue never resolved in the book is that of the
contribution of substance abuse to acute psychosis and violence and to the
reduced effectiveness of community care. Torrey defines the focus of the book
as ‘severe mental illness’. He excludes substance abuse from that definition
although acknowledges that drugs such as alcohol, marijuana, cocaine and PCP
make a major contribution to mental illness. However substance abuse,
especially its endemic forms in major cities, is an uncomfortable fit within
any biological theory of mental illness.

While there might be room for argument about the
conceptualisation of mental illness and the appropriate degree of paternalism
in mental health care, there can be little argument that the byzantine
structures of funding for mental health services in the United States have a
large role to play in the fragmentation of services and the uneven provision of
services within and between states. Torrey reviews the cost shifting made
possible by moving patients from hospitals provided and funded by states, to
services, such as general hospital beds provided by the states but funded from
federal grants. It seems that in many states more energy has gone into
channeling patients into the service that makes the least demand on state
resources, regardless of whether this serves the interests of the patient.
Similarly, the splitting of responsibility for provision of income support from
provision of treatment creates a perverse incentive to continue payments
without incurring the costs of providing treatment. This means that income
support payments are made but without any attempt to encourage the recipient
into treatment. There are other mechanisms which militate against involvement
in treatment by rewarding organisations which prevent people from receiving
services The solution of single responsibility seems eminently sensible, and
Torrey suggests that it would lead to the development of practicable
alternatives to hospitalisation. However single responsibility funding seems
unlikely to be achieved given its political implications.

In his dismissal of social models of mental health and
illness Torrey is at odds not only with advocates of greater autonomy for
people with mental illness, but with medical colleagues and researchers who
recognise the social basis of many illnesses with a more legitimate claim to
biological causes than mental illnesses. Diabetes, heart disease, HIV/AIDS and
some forms of cancer come to mind as ‘biological’ illnesses which are
responsive to social interventions. Psychiatry has long sought to establish its
legitimacy by demonstrating that it too is a branch of medicine that
investigates real diseases that respond to medical treatments, and Out of the Shadows can be seen as part
of that tradition. Ironically, this denies psychiatry’s enormous contribution
to health care made by embracing the social model of community mental health
care.

The book is liberally illustrated with examples designed to
support the major arguments of each chapter. The ready availability of such a
stream of case studies illustrates the ubiquity of the issues raised, if not
the correctness of Torrey’s explanation for them. At every turn there is another
homeless person, jail inmate, abuse victim or violent offender whose plight can
be sheeted home to deinstitutionalisation or an insufficiently assertive
approach to care and treatment.

Out of the Shadows is motivated by concern for
the plight of the mentally ill. Reading it, I sense the impatience of someone
who feels constrained to stand by while those who might benefit from his
clinical skills and ethical commitment unwisely choose to decline that help.
Adding to Torrey’s frustration is that, in his view, professionals who should
know better adopt a liberal view of the human rights of the mentally ill which
supports those mistaken choices. But the cause of the mentally ill will not be
advanced by the blind assertion of an ideological position of either a
biological or social basis for mental illness. Much of the history of mental
health care is a history of disappointed idealism and resigned coercion. While
the beneficent intent of a more assertive mental health regime can be
acknowledged, even lauded, the danger is that it may pander to public and
professional prejudice. The result could be that an admirable intent may
disguise a state-sponsored encroachment of liberties that would not be
tolerated in any other group of citizens.